Clinical Exemplar MAY 2004, VOL 79, NO 5

C L I N I C A L E X E M P L A R

Protect your patient-It is never too late to reposition

ven when patients are posi- tioned properly for surgery, some obstacles may arise. A patient’s shape and weight can E present a challenge for optimal

position& Vigilant obs<rvation&of a patient’s position, preoperatively and intraoperatively, is imperative to pre- vent dire consequences.

CAsE STUDY Ms J was scheduled for a posterior

lumbar decompression and fusion. Ms J is morbidly obese with a height of 5 ft 6 inches and weight of 253 Ibs. Her size presented some concern about how sur- gical team members would position her prone on the spinal surgery and imag- ing table.

During Ms J’s interview, the circulat- ing nurse verified consent and deter- mined that Ms J understood the proce- dure. This procedure may include plac- ing pedicle screws in the lumbar area. At the time this patient was undergoing surgery, the hospital was undertaking a study of this procedure, so the patient also signed a study consent form. The circulating nurse assessed the patient’s laboratory results to identify abnormali- ties, such as below normal hematocrit and hemoglobin levels and prolonged prothrombin time and partial thrombo- plastin time. The circulating nurse veri- fied the availability of blood products by ensuring that the patient’s blood had been typed and cross matched, because a sigruficant amount of blood loss can occur during this type of procedure.

The circulating nurse and anesthesia care provider discussed postoperative expectations, such as wound drainage; indwelling urinary catheter placement; dressings; and invasive lines, such as IV arterial lines, with Ms J. The patient and her family members were inform- ed that the procedure might last eight

hours or more. Family members were told that they could contact the OR to receive an update on the progress of the procedure and Ms J’s status from patient relations personnel.

POSITIONING THE PATIENT After the anesthesia care provider

completed intubation and placed venous and arterial lines, the circulat- ing nurse inserted the indwelling uri- nary catheter and applied antiem- bolism stockings and a sequential com- pression device. With the patient on a stretcher next to the spinal surgery and imaging table, support pads for her chest, hips, and thighs were placed in their approximate locations. The patient then was transferred with the anesthe- sia care provider at her head, two team members on either side, and one team member at her feet. At least six people are needed to safely transfer a patient from the stretcher to the spinal surgery and imaging table.

Ms J’s gown was removed immedi- ately before she was turned to prevent any wrinkling of the gown underneath her, which could cause skin irritation. The patient was turned using the log roll method. Her head was placed face down on a foam prone pillow to pro- tect pressure points, such as her fore- head and chin. The anesthesia care provider lubricated and closed Ms J’s eyes and secured eye pads on top for protection.

care provider worked cooperatively to properly align Ms J’s arms on the arm boards-her shoulders were not posteri- orly or superiorly extended, her elbows were at a 90-degree angle, and her hands were pronated to prevent brachial nerve damage. Her arms were placed on egg crate foam to protect the pressure points of the elbows and wrists.

The circulating nurse and anesthesia

Mma Lisa -pa4dm

AORN JOURNAL 1017

MAY 2004, VOL 79, NO 5 Clinical Exemplar

Although the procedure was well under way when the patient‘s position Changed, if the patient was not repositioned, she might

experience severe, wen life-threatening, injuries.

The chest pad, with a gel pad on top to protect the patient’s chest pressure points, was adjusted so that the top of the chest pad was at the patient’s suprasternal notch. The circulating nurse and surgeon ensured that the load of the patient’s chest was mainly on the superior aspect of the chest to minimize pres- sure on her breasts. This also facilitates ventilation. This position also is better tolerat- ed when the patient‘s breasts are medial and cephalad.

The circulating nurse placed hip pads with egg crate foam under the patient’s iliac crest to prevent hyperex- tension of her lower back. The thigh pads with egg crate foam were adjusted under the patient’s thighs and up against the hip pads for lower body support. The patient’s legs were placed on pillows to bend her knees slightly to pre- vent peroneal and popliteal nerve damage. A suspension sling and egg crate pads were placed under the patient’s feet to protect pressure points. The circulating nurse placed a safety strap padded with a blanket snugly around the patient’s thighs. The circulat- ing nurse then prepped the patient, after which the scrub person and surgeon draped the patient, and the procedure began.

REPOS~ONING THE PATIENT In the exposure phase of

the procedure, the anesthesia care provider stated that he was no longer satisfied with the patient’s position. The cir-

culating nurse noticed that Ms J’s position was no longer optimum; her neck was hyperextended, and lordosis was very pronounced.

The anesthesia care provider assumed that because the surgeons were well into the procedure, the patient could not be reposi- tioned. If the patient was not repositioned, however, she could experience severe injuries. With her neck hyper- extended, her airway might become obstructed and nerve damage could occur. Her shoulders were overextended, which could cause brachial nerve damage. The anatomi- cal position of her spine could not be viewed optimally because of the pronounced lordosis, and this could pro- long the procedure. If action was not taken to correct these problems, further changes to her position and skin sheering could occur.

immediately notified the sur- geons of the change in Ms J’s position and insisted that the procedure be halted so the patient could be repositioned. Surgical team members worked cooperatively in an effort to reposition Ms J. They were unable to reposition her successfully without contami- nating the sterile field, how- ever, so the scrub person cov- ered the patient’s wound with a sterile adhesive drape and removed all other drapes. In this way, swgical team mem- bers were able to visualize the patient’s entire body again and see that the hip and thigh

The circulating nurse

pads had shifted. The surgeons and anesthe-

sia care provider lifted Ms J, and the circulating nurse and scrub person repositioned the hip and thigh pads as they had been before and then secured them with strong cloth tape. Moddymg and securing the positioning devices prevented any more changes in the patient’s posi- tion. Surgical team members then reprepped and draped the patient.

The procedure was com- pleted without any dire con- sequences because of vigdant observation and the nurse’s insistence on proper reposi- tioning. Ms J’s neurological status remained intact, her skin integrity was main- tained, and she did not acquire an infection.

duty is to be alert to any threat that could affect patients in the OR. Proper techniques must be followed diligently throughout the procedure, whether that means having blood products available, informing the patient and his or her family members of expected out- comes, or repositioning when a procedure already is under- way. Perioperative nurses must always be the patient’s advocate. *:*

The circulating nurse’s

MONA LISA MACAPAGAL RN, CNOR

NURSE CLINICIAN Iv AND Rh‘ FIRST ASSISTANT

THE UNIVERS~ OF T o w MEDICAL BRANCH GALVESTON

GALVESTON, Toc

1018 AORN JOURNAL